Management of Status Epilepticus in the Prehospital setting

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Status epilepticus (SE) is a time sensitive neurological emergency that requires rapid recognition and intervention to prevent long-term complications. This review explores current evidence and best practices for the prehospital and emergency department management of SE, focusing on early recognition, diagnostic tools, and pharmacologic strategies. Literature was sourced from PubMed using predefined keywords and inclusion criteria, emphasizing studies published within the last decade. The review highlights the challenges in prehospital care, particularly delays in treatment due to difficulties with intravenous access and underutilization of alternative drug delivery routes. Benzodiazepines (BZDs) remain the first-line therapy, with intramuscular midazolam emerging as a practical option when Intravenous (IV) access is not available. Non-IV routes such as Intranasal (IN) and buccal administration offer similar efficacy and are increasingly supported for prehospital use. Point-of-care EEG (PocEEG) shows promise in improving diagnosis, especially for non-convulsive status epilepticus (NCSE), though its adoption remains limited. Key gaps include lack of rapid diagnostic tools in the field, restricted availability of second-line agents, and underdosing due to fear of respiratory depression. Future directions should focus on protocol optimization, expanding access to non-invasive rescue therapies, and integrating diagnostic innovations into emergency systems. Effective prehospital SE management depends on timely seizure control using the most accessible route, coupled with system-wide efforts to reduce treatment delays and improve patient outcomes.